The distal radioulnar joint and tfcc

An overview of the anatomy/physiology of the distal radiaoulnar joint, TFCC, and it's clinical significance.

1. The Distal Radioulnar Joint and TFCC Anatomy and Clinical Significance Rafael E. Salazar II, OTR/L

2. Bony Anatomy of the DRUJ Articulation of the ulnar notch of radius and it’s ulnar axis. Articulation of the proximal carpal row and the distal ends of the radius Scaphoid Lunate ( LaStayo , 2006) Distal Radioulnar Joint:

3. Extrinsic Soft Tissue Stabilizers of DRUJ Pronator Quadratus Interosseous Ligament Tendon of Extensor Carpi Ulnaris (ECU) Tendon sheath blends with the TFCC

4. Intrinsic Soft Tissue Stabilization Joint Capsule Continuous with RU Ligaments of TFCC and ECU Sheath Ligamentous Attachments TFCC Ulnocarpal Ligaments ( Wijffles , 2012)

5. Anatomy of the TFCC The Triangular Fibrocartilage Complex The Five Parts: Triangular Fibrocartilage Disc (articular disc) Volar and Dorsal Radioulnar Ligaments (Superficial & Deep) Meniscus Homologue Ulno-colateral & Ulno -carpal Ligaments Tendon Sheath of ECU ( Wijffles , 2012)

6. Anatomy Cont.

7. Functions of the TFCC Provides gliding surface across distal face of both radius and ulna Stabilizing mechanism of the DRUJ during rotational movement supination/pronation Suspends the ulnar carpus from contacting the distal ulna/radius Cushions forces that are transmitted through the ulnocarpal axis Connects the ulna to the volar carpus (Coker, 2010)

8. Stability: TFCC Injuries: Importance of TFCC Prevents dislocation of the radius as it rotates around its ulnar axis Suspends the ulnar carpus over ulna Instability of the DRUJ Dislocation of ulna Decreased rotational movement Ulnar Impingement Causes a (+) ulnar variance Pain with ulnar deviation & supination

9. Biomechanics & Movement 180 Degrees of Rotational Movement Pronation Supination Translational Movement of Ulna During Pronation and Supination Pronation: Dorsal Supination: Palmar ( Wijffles , 2012)

10. Pronation Supination Biomechanics Cont. TFCC: Radioulnar Ligaments Tighten and Loosen During Rotational Movement Pronation Dorsal Superficial & Deep Palmar Fibers Tighten Supination Palmar Superficial & Deep Dorsal Fibers Tighten Neutral

11. Etiology: TFCC Injuries Traumatic Injuries/Lesions (Class 1) Falls on outstretched, pronated hand Acute rotational injury Distraction Force Degenerative Injuries/Lesions (Class 2) Repetitive movement Hypovascularity and poor nutrition Central portion of TFCC Anatomical Variation + Ulnar variance ( Wijffles , 2012)

12. Symptoms of TFCC Injury Ulnar sided wrist pain Popping/clicking with pronation/supination Decreased rotational movement Decreased grip strength Instability of the DRUJ (Coker, 2010)

13. DRUJ Instability

14. Diagnosis of TFCC Injuries DRUJ Stability Tests Piano Key Test: Tests Static DRUJ stability Rule Out Alternative Causes: Radius Pull Test Interosseous Membrane Clunk Test Interosseous Membrane ECU Test Extensor Carpi Ulnaris Tendon ( Wijffles , 2012)

15. Diagnosis of TFCC Injuries Cont. Physical Assessment of the TFCC Palpable tenderness over the TFCC Combined ulnar deviation and pronation/supination may cause pain and popping/clicking sounds Ulnar Impingement Sign TFCC Stress Test “ Press Test”: has been shown to have 100% sensitivity for TFCC tears ( Wijffles , 2012)

16. “Press Test” for TFCC Patient is asked to lift himself/herself out of a chair while bearing weight on extended wrists Pain at the wrist indicates TFCC tear/lesion

17. Radiological Assessment X-ray Ulnar Variance Is Calculated (+) Is Associate With TFCC Tears MRI The radioulnar ligaments, ulnocarpal ligaments and the TFCC with it foveal attachment to ulna can be visualized 86% Sensitivity for detection of TFCC tears (Thomas, 2012)

18. Conservative Treatment for TFCC Lesions Splinting for a period of time to reduce symptoms Followed by progressive ROM and strengthening exercises If patient’s symptoms have not been resolved in 4-6 weeks, surgical repair or debridement should be considered. Conservative treatment is thought to be ineffective for chronic (>6 mo.) ( Baek , 2012)

19. Central Debridement Peripheral Repair Surgical Interventions As 80% of the central TFCC is avascular with poor healing potential, damage to this area is usually treated with debridement. Arthroscopic or Open Common for Type II Lesions Ligaments are directly repaired Avulsed portion of TFCC is debrided and the torn border is sutured to the fovea Usually open Lucio et al, 1991

20. Postoperative Therapeutic Management Wound care/Scar managemnet Edema Control Splinting To protect the integrity of the repair Per protocol/surgeon’s recommendations (Coker, 2010)

21. Postoperative Management Cont. Maintain and improve ROM Digits/ Uninvolved Joints initially Goal is to maximize pain-free wrist and forearm AROM Follow protocol/surgeons guidelines for when to initiate wrist PROM/AROM and strengthening (Coker, 2010)

22. Outcome Measures Grip Strength Dynamometer ROM Measurements From Wrist Goniometer ***Patient Specific Goals/Outcomes

23. References Baek G, Kato H, Romanowski , L. Distal radioulnar joint instability. IFSSH Scientific Committee on Bone and Joint Injuries. 2012. Coker D. Anatomy and dysfunction of the DRUJ and TFCC. South County Hand Center . 2010. LaStayo P, Lee M. The forearm complex: anatomy, biomechanics and clinical considerations. J Hand Ther . 2006. Lucio BT, Stokes HM, Phoehling GG, Lemoine -Smith S, Crook E. Management of isolated triangular firbrocartilage complex perforations of the wrist. J Hand Ther . 1991; 162-168 . Snell C. (2012) Triangular fibrocartilage complex tears: evidence based assessment and management. The Sports Physiotherapist. Retrieved from http://www.thesportsphysiotherapist.com/triangular-fibrocartilage-complex-tears-evidence-based-assessment-and-management/ Thomas B, Sreekanth , R. Distal radioulnar joint injuries. Indian J Orthop . 2012; 493-504. Wijffels M, Brink P, Schipper I. Clinical and non-clinical aspects of distal radioulnar joint instability. The Open Orthopaedic J. 2012; 204-210.

24. Questions?